Epidemics (maraka)

From the above discussion it is evident that ancient Indian medicine had come to recognise the close association of the seasons with the state of health or with prevalence of disease. The knowledge of the states of the weather and the environment was essential for the physician to understand how unusual changes in the seasons and the natural environment affect health and disease. Great significance is attached to the appearance of unnatural characteristics in the stars, the planets, the moon, the sun, air, fire and the diks (directions) as they are understood to portend an event of a very grave nature, that is, epidemic disease.^[1]

Control of an epidemic situation is an enormous challenge for not only for the physician but for the administration as well owing to its lasting impact on the economy and the society. Comparing the effects of disease and epidemic, Kautilya points out that the former afflicts only one region and remedies can be found for it, while famine afflicts the whole country and leads to the absence of livelihood for living beings. The impact of an epidemic can be understood in the same way.^[2] The large-scale loss of human and animal resources undoubtedly constituted a disaster for the economy and the society.

Epidemic disease in conventional wisdom has been attributed to supernatural forces. The Arthaśāstra describes disease and epidemic (maraka), along with fire, floods and famine, as divine afflictions (daivapīḍanam). Epidemic (pramāra) also figures in another list of calamities (āpadaḥ) caused by the gods.^[3] The classical medical writers however, postulate an association of epidemic diseases with the environmental factors, that is, factors are common to all residents of a locality. Thus, according to Caraka Saṃhitā, even though the physical constitutions of individuals differ, certain factors are common to the inhabitants of a locality (janapada) -air, water, location and the seasons (time/kāla). This explains the manifestation of disease conditions with similar symptoms in a large population that accounts for mass deaths, and the consequent destruction of large settlements (janapadoddhvaṃsa).^[4] When the seasons deviate from the normal course and exhibit unnatural characteristics, there is unseasonal weather, excessive dryness or wetness, heat or cold, etc. In these conditions, the other essential elements -air, water, the locale -also lose their usual properties and develop anomalies.

Plants growing in these deviant conditions cannot remain unaffected. Aberrations become evident in their properties-taste, potency and vipāka as well as pravābha (specific action in drugs). These aberrations, according to Caraka, are generative of diseases of an epidemic nature (janapadoddhvaṃsakarāṇāṃ vikārāṇāṃ).^[5] Suśruta also has a similar explanation of pestilence. In the normal transition of the seasons, water and vegetables retain their natural properties. However, deviation from the normal course of things occurs when unforeseen factors cause abnormal cold, heat, wind and rain. Such conditions produce unwholesome effects on plants and water whose consumption is then responsible for the onset of diseases and the outbreak of epidemics (maraka).^[6]

Caraka describes the characteristics of air, water, habitat and time that do not bode well for health and are symptomatic of some calamitous event in the nature of an epidemic.

The ominous characteristics of atmospheric conditions (vāta/air) are:

1. The absence of the normal seasonal characteristic features;
2. Excessive stillness or violent winds;
3. Excessive aridity, cold, heat, roughness or humidity;
4. When masses of air clash into each other;^[7]
5. Presence of cyclonic winds (ati kuṇḍalinam);
6. Presence of unwholesome odour, gases, sand, ash and smoke.^[8]

The characteristics of water that are symptomatic of abnormalities are:

1. Alteration in smell, colour, taste and touch;
2. Appears putrefying;
3. Absence of aquatic birds;
4. Diminution in the number of aquatic animals;
5. Manifestation of unpleasantness.^[9]

Presence of the above characteristics in water is symptomatic of contamination. Varāhamihira associates any unusual phenomena near water bodies or change in the smell and taste of water with fear in the land.^[10] If wells are found to blaze, to smoke, to boil, to weep, to call, to sing or to spring, then they are portentuous of an epidemic (janamaraka).^[11] The same is indicated by the occurrence of unpleasant odour, gases, sand, ash and smoke in air (as noted above). Reference to impure air as causative of maladies is found in Suśruta’s work as well. It is said, sometimes, where the air is affected by the fragrance of flowers of poisonous plants, people suffer from cough, asthma, nausea, common cold, headache and fever irrespective of their constitution and balance of the doṣas.^[12]

Diseases afflicting a large population at the same time can also be attributed to insalubrious terrestrial characteristics.

A place having the following features is regarded as harmful to health:

1. There is distortion of the natural colour, smell, taste and touch;
2. There is excessive moisture;
3. It is marked by abundance of serpents, wild animals, mosquitoes, locusts, flies, rats, owls, vultures, and jackals;
4. There is overgrowth of grass and weeds;
5. The place abounds in creepers and other vegetation unlike anything before;
6. The crops have withered away or have dried up or are destroyed;
7. The wind is smoky;
8. There is constant screeching of birds and howling of dogs;
9. Animals and birds move about in bewilderment and pain;
10. It is characterised by the perversion or absence of virtue (dharma), truth (satya), modesty (lajjā), customs (ācāra), moral precepts (śīla) and other good attributes by the inhabitants;
11. The lakes or reservoirs are constantly agitated and water flows over;
12. Meteorites, thunderbolts and earthquakes are of frequent occurrence;
13. There is dreadful howling and frightful sights;
14. The sun, the moon and the stars frequently covered by a net of clouds that are rough, coppery, reddish or white;
15. It appears as if there is confusion, agitation, fear, lamentation and darkness in the environment;
16. There is excessive howling as if the place is being seized by demons.^[13]

Time is also a causative factor for manifestation of epidemic diseases when there is aberration of the normal features of the seasons. These features may be more than, less than or opposed to those that are proper to it at any particular season.^[14] Thus, vitiation of these four conditions, air, water, habitat and seasons, bring about epidemics.^[15]

Caraka’s analysis of the conditions that render a locale prone to mass outbreaks of diseases encompass a range of causes -from edaphic, biotic, meteorological to cultural. Essentially changes in weather patterns affect the properties of plants (drugs) which in turn result in the widespread manifestation of diseases.^[16] Many of these features, in fact, can be related to regions that receive copious rainfall -such as presence of excessive moisture in the soil, infestation of reptiles, mosquitoes, flies, etc., overgrowth of grass, weeds, luxuriant vegetation, turbulent water bodies that overflow, frequency of thunderbolts and earthquakes, and the constant cloud cover in the skies. Copper or red colour of the sky also suggests the presence of moisture in the atmosphere. It is known that persistently wet conditions cause plants to rot and produce dampness that favours the growth of moulds as well as generation of insects. Such ecological conditions are unsuitable for sanitized human habitation. On the other hand, the reference to withered or dried crops suggests a very dry type of climate or drought condition that engenders famine and malnutrition rendering the body susceptible to infections.

Among the conditions identified by Caraka as generative conditions of epidemic diseases, four are important: climatic conditions, air pollution, water contamination and ecological conditions. This observation has striking concordance with modern epidemiological concepts to an extent. According to the World Health Organisation, a number of environmental factors influence the spread of communicable diseases that are prone to cause epidemics. The most important of these are-water supply, sanitation facilities, food and climate.^[17]

Another observation of the medical authors is significant here. One of the causative factors identified by Caraka is the conformity to certain accepted social and cultural norms, such as, righteousness, truth, modesty, customs and moral precepts. The normative base of ethical precepts and behaviour being derived from the brahmanical society, the statement may be understood as an indictment of communities which do not adhere to the prescribed brahmanical norms. Here, disease is directly attributed to human agencies. The attribution of a somewhat similar assertion is made by Suśruta too, though the tone is less strident. A large populated area (janapada) may also be devastated by unnatural occurrences, such as kṛtyā (black magic), abhisāpa (curse), anger of demons and adharma (unrighteousness).^[18] Varāhamihira echoes similar notion when it is declared that the country will suffer miseries if the ruler respects heretics (pākhaṇḍānāṃ) and ascetics (nāstikānāṃ) or if he refuses to abide by the rules of life observed by the great and holy men of the land.^[19]

The acuteness of the outbreak is determined by the nature of the causative agent. Contamination of water is more serious than that of air because it is harder to avoid; aberrations of the locale are graver than that of water, and the factor of time is more severe than the factor of locale.^[20] Unseasonal weather and its effects are by far the most serious for health as it is most difficult to remedy.^[21] The medical authorities also speculated on the factors behind these uncharacteristic environmental occurrences. In reply to a question from Agniveśa on the origins of epidemics, Ātreya explains that the cycle of causation arises from the abnormalities of the land, the season, the air and water. The root cause of the vitiation of these natural elements is identified as unrighteousness (adharma) or bad deeds of the past life (asatkarma pūrvakṛtaṃ). Both have their source in the violation of good judgement (prajñāparādha). Thus, when the leaders of country, town, guild or district transgress the path of righteousness and they conduct themselves with their subjects in an unrighteousness manner (deśa-nagara-nigama-janapada-pradhānādharmamutkramyādharmeṇa prajāṃ vartayanti). In this manner, their subordinates and subjects of the towns and the cities, as well as the merchants add to this immorality. Their unrighteous acts completely obscure virtue [tataḥ so(a)dharma prasabhaṃ dharmamantardhatte] so much so that the gods desert the people living in these places. These are the places where the seasonal aberrations occur. Consequently, it does not rain at the proper time, or there is no rainfall at all or there is abnormality; the winds do not blow properly; the earth suffers misfortune; the waters dry up; plants lose their natural properties and become impaired. Then, they bring destruction on the localities because of there is morbidity in touch and edibles (tata uddhvaṃsante janapadāḥ spṛśyābhyavahāryadoṣāt).^[22]

The correlation between unrighteousness acts of the king and its consequences for his subjects is known from other sources too. According to Varāhamihira, the effects of the sins of the king in his former birth are felt not only by the king himself, but also affect his children, the treasury, the vehicles and carriage animals, the town, wives, priests and his subjects at large.^[23]

Ātreya goes on to say that unrighteousness is also at the root of destruction of country by war. Some people driven by greed, anger, delusion and pride initiate hostilities against their own people.^[24] Annihilation of large settlements can also be brought on by sinful behaviour in two ways: (i) unrighteousness invites the assault of rākṣasas and other such creatures;^[25] (ii) it provokes the righteous to curse those indulging in such immoral behaviour. Those who have no place for virtue in their lives, show disrespect to their preceptors, elders, saints and sages and indulge in immoral acts. They are cursed by the worthy, and in the process men and families are destroyed.^[26]

The perception of a direct correlation between righteousness and well being, both physical and psychological, appears well rooted in ancient medical theory. Ātreya’s exposition on the attributes of humans in the four mythic ages is a pointer in that direction. Ātreya describes how with the passage of time the lifespan of humans gradually decreased as they grew increasingly unvirtuous. Since the beginning of creation, inauspiciousness has always arisen from unrighteousness and there has never been any other source.

During the first age, satyayuga, people were as energetic as the gods. They were exceedingly pure and powerful (ativimala-vipulaprabhāvāḥ). They could see the gods, the divine saints, virtue, the precepts and performance of the yajña (sacrifice) with their own eyes. Ātreya then describes the excellence of their physique and psyche. Humans in this age were the embodiment of truthfulness, simplicity, non-violence, charity, self-control, observance of rules, meditation, fasting and celibacy. On the other hand, they were devoid of fear, attachment, envy, delusion, greed, anger, grief, illness, excessive sleep, drowsiness, fatigue, exhaustion, laziness and possessiveness. Hence, they were blessed with an unlimited lifespan (puruṣā babhuvuramitāyuṣāḥ). During this age, even the earth and the other elements were imbued with the best qualities. The crops produced were of excellent taste, potency, vipāka and prabhava.^[27]

At the end of satyayuga, decline set in when some affluent individuals became corpulent owing to overindulgence. Corpulence caused fatigue, which in turn led to laziness, possessiveness, attachment and greed. During the tretāyuga, malice appeared from greed, and from malice, untruthfulness, passion, anger, vanity, hatred, cruelty, violence, fear, sorrow, grief, worry, anxiety, and so on. A quarter of virtue (dharma) disappeared, and the human lifespan also suffered a proportionate diminution. The impact of such decay was also felt in the natural elements, according to Ātreya, which also lost their attributes by a quarter. It was, therefore, inevitable that the earth’s produce equally lost its nourishing properties. The negative impact was the disruption of the equilibrium of the doṣas occasioning the manifestation of disease and diminution of longevity.^[28]

Thus, Ātreya quotes the saying:

yuge yuge dharmapādaḥ karmaṇaenaṃ hīyate.
guṇapadāśca bhūānāmevaṃ lokaḥ pralīyate.^[29]

“From age to age, step to step, one quarter of righteousness is lost. And creatures too lose one quarter of their goodness. And thus the world falls apart.”^[30]

Ātreya’s discourse clearly establishes the functional correspondence between human psyche and the human body through the agency of the natural elements. Unvirtuous conduct affects the body through the agency of diet and regimen in the form of disease. It is significant that this lengthy background to the origin of illness is not given in the Nidāna-sthāna, which is an exposition on the causative factors of disease, or more specifically on the immediate factors. The distant causes (attributed to the past unvirtuous acts) are elucidated in the chapter entitled, janapadoddhvaṃsanīyaṃ of the Vimāna-sthāna, and there may be a reason for doing so. While the ancient physicians have the understanding that deterioration of the natural elements brings on diseases, it becomes less easy to comprehend why people sharing the same environmental conditions but of different constitutions (prakṛti) should be afflicted with the same disease at the same time.

The hypothesis of unvirtuous deeds, previous and present, is important in the context of outbreak of epidemic diseases:

(i) First, it explains why the air, the water, the land and the seasons lose their natural properties and manifest abnormality;

(ii) Secondly, it helps to account for the outbreak of the same disease in a large community despite the significant degree of heterogeneity in individual constitutions;

(ii) It also becomes necessary to postulate this theory in order to comprehend the occurrence of fatalities on a large scale despite the conviction that epidemic diseases are remediable and that there is no cause for apprehension if proper medicaments are at hand.^[31] At a time when the concept of immunity were nowhere on the horizon, it was difficult to comprehend why some could still escape death in the midst of so many fatalities. If some people remain unaffected, it can be accounted for by the nature of their deeds. Those who do not have the identical actions during the past lives (identical with those suffering from the disease), and those who are not destined to die during the epidemic, the five elimination therapies or pañcakarma are best for them.^[32]

It is significant that the texts do not refer to any special formulations to be administered in epidemics other than the five elimination and rasāyana therapies, and drugs that have been collected before the onset of the outbreak.^[33] Besides, a host of spiritual therapeutic measures are advised during such occurrences. These are truthfulness, compassion for living beings, charity, sacrifices, prayers, adoption of preventive measures through good conduct (sadvṛtta), tranquility, protection of the self by mantras, search for things that are good for the self, residence in auspicious localities, observance of brahmacarya, discussions of religious scriptures with great sages and those who have self-control, and constant association with religious, sāttvika and learned persons.^[34] No extraordinary precautionary measures other than those of sadvṛtta, are prescribed here. Residence in auspicious localities may indicate shifting to clean places.

Change of place (sthāna-parityāga) is advised by Suśruta along with the similar suggestions-pacifying action (śāntikarma), atonement (prāyaścitta), auspicious rites (maṅgala), incantation (japa), lighting of sacred fire (homa), offerings (uphāra), sacrifices (ejya), salutation with folded hands (añjali-namaskāra), penance (tapa), religious observance (niyama), compassion (dayā), charity (dāna), initiation from the preceptors (dīkṣā), and devotion to the Gods, brāhmaṇas and teachers for the restoration of well being.^[35] Similar opinion is available in other texts-Varāhamihira opines that effects of stellar phenomenon (related to planets and stars) can be assuaged by large gifts of gold, food, cows and lands, by koṭihoma (sacrificial offering), etc.^[36]

The absence of extraordinary therapeutic measures to cope with such calamitous events is indeed striking. We are in the dark about how such outbreaks affected different strata of society. Even more curious is the absence of a separate chapter dealing with epidemic outbreaks in Suśruta’s compendium wherein the subject has been dealt with cursorily. In fact, taken as a whole, our information about epidemics is quite meagre in our sources.

Footnotes and references:

[1]:

Caraka Saṃhitā Vimānasthāna 3.4.

[2]:

Arthaśāstra 8.4.7-8.

[3]:

Arthaśāstra 9.7.82.

[4]:

Caraka Saṃhitā Vimānasthāna 3.6.

[5]:

Caraka Saṃhitā Vimānasthāna 3.4.

[6]:

Suśruta Saṃhitā Sūtrasthāna 6.15-17.

[7]:

This refers to storm conditions for it is known that when an air mass clashes with another having a different temperature and humidity, it can result in a storm.—National Geographic Education Encyclopaedia; http://education.nationalgeographic.com/education/encyclopedia/air-mass/?ar_a=1 (Accessed on 23.1.2013).

[8]:

Caraka Saṃhitā Vimānasthāna 3.7(1).

[9]:

Caraka Saṃhitā Vimānasthāna 3.7(2).

[10]:

Shrikrishna “Jugnu”, J.H.C. Kern (Eds.) and N.C Iyer, (trans.), Bṛhat-Saṃhitā of Varāha-Mihira, Vol.1, Delhi, 2013, 46.50. Hereafter Bṛhatsaṃhitā.

[11]:

Bṛhatsaṃhitā, 46.49.

[12]:

Suśruta Saṃhitā Sūtrasthāna 6.19.

[13]:

Caraka Saṃhitā Vimānasthāna 3.7(3).

[14]:

Caraka Saṃhitā Vimānasthāna 3.7(4).

[15]:

Caraka Saṃhitā Vimānasthāna 3.7.

[16]:

Caraka Saṃhitā Vimānasthāna 3.4.

[17]:

WHO Webpage, “Environmental Factors in Emergencies”; http://www.who.int/environmental_health_emergencies/disease_outbreaks/communicable_dis eases/en/ (Accessed on 28.02.2013).

[18]:

Suśruta Saṃhitā Sūtrasthāna 6.19.

[19]:

Bṛhatsaṃhitā 46.76.

[20]:

Caraka Saṃhitā Vimānasthāna 3.9-10.

[21]:

Caraka Saṃhitā Vimānasthāna 3.11.

[22]:

Caraka Saṃhitā Vimānasthāna 3.20.

[23]:

Bṛhatsaṃhitā, 46.7.

[24]:

Caraka Saṃhitā Vimānasthāna 3.21.

[25]:

Caraka Saṃhitā Vimānasthāna 3.22.

[26]:

Caraka Saṃhitā Vimānasthāna 3.23.

[27]:

Caraka Saṃhitā Vimānasthāna 3.24.

[28]:

Caraka Saṃhitā Vimānasthāna 3.24.

[29]:

Caraka Saṃhitā Vimānasthāna 3.25.

[30]:

Translation taken from D. Wujastyk, The Roots of Āyurveda: Selections from Sanskrit Medical Writings, New Delhi, 2001 (revised edition), p.85.

[31]:

Caraka Saṃhitā Vimānasthāna 3.8.

[32]:

Caraka Saṃhitā Vimānasthāna 3.13.

[33]:

Caraka Saṃhitā Vimānasthāna 3.13-14.

[34]:

Caraka Saṃhitā Vimānasthāna 3.15-17.

[35]:

Suśruta Saṃhitā Sūtrasthāna 6.20.

[36]:

Bṛhat-Saṃhitā, 46.6.